Financial incentive programs have been available in the medical profession for quite some time. For example, pay-for-performance programs are incentive-based programs that reward members in the health care community (e.g., doctors, hospitals, pharmacies) for meeting pre-established targets for delivery of healthcare services. These targets for delivery of healthcare services could cover a variety of fields in the healthcare industry including, but not limited to, adherence to one or more medication regimens, reduction of hospital readmissions, and/or timely participation in medical detection processes (e.g., receiving a mammogram when the patient is of a certain age).
In fact, there are many examples in health care of financial incentives (or negative incentives/penalties) offered by health insurers, pharmacies, pharmacy benefit managers, health care delivery systems, or pharmacy chains to health care professionals in exchange for performing particular services at defined levels. For example, a bonus can be achieved when a health care provider ensures that a certain percentage of the eligible patient population adheres to a drug therapy (e.g., blood pressure medication) according to clinical guidelines. Incentives can also be achieved based on defined performance quality measures. For example, a bonus can be achieved when a health care provider ensures that average blood sugar levels among eligible patients do not surpass certain levels.
Bonus payments are typically calculated as a function of an available bonus pool (e.g., an amount of money) divided by the number of expected or potential bonus payouts. In other cases, the magnitude of bonus payments may, for example, be simply benchmarked to industry norms or set as an amount that is believed to be conducive to induce provider engagement and participation.
However, there are certain drawbacks to these programs. For example, these incentive programs are generally applicable to a large population of patients where the rewards are distributed to healthcare professionals on behalf of the measured performance of patients across the population. That is, the bonus pool is allocated evenly for each individual in the population thus making the incentive associated with each individual relatively small when the population is large.
A fundamental shortcoming in the art is a lack of technology or set of analytic processes that systematically calculates and offers a financial bonus payment to a health care professional that is determined by the factors mentioned above, as well as the predicted risk profiles of patients eligible for inclusion in quality measures and the expected financial or economic benefits that could accrue if patients achieve performance goals as intended by the bonus payment scheme itself (e.g., if population-level increases in medication adherence are achieved as intended by the bonus available to relevant health care professionals, the average expected cost of those patients will fall by a specific, predictable amount). Another shortcoming in the art is that there is no technology that is directed to prediction-driven or prediction-derived outcomes payments to health care professionals designed to return the increased (or even maximized) economic gains while reducing (or even minimizing) program and bonus payment costs. Thus, there is a need for a system that improves upon these drawbacks and provides for solutions mentioned above.
The technology described herein relates to using predictions about patients' future health care outcomes (e.g., patients' expected future adherence to medication regimens) and the expected economic benefits of targeted improvements on certain performance measures (e.g., reduced likelihood of hospitalization attributable to more consistent medication use). Certain technology related to predicting patients future health care outcomes is described in commonly assigned U.S. patent application Ser. No. 13/729,817, the entire contents of which are incorporated herein by reference. These factors help compute which subset of patients should be included in a payment scheme and what the specific bonus payment amounts should be such that expected benefits from better patient outcomes, once realized, outweigh the expected costs of the payment scheme itself. While the description herein is made with respect to a medication adherence example, it will be understood that the description in this regard is illustrative and non-limiting. The technology described herein may be applicable to any of a wide range of conditions and incentive programs.